1. Global Training Network ProgrammeWorld Health Organization

2. Global Training Network ProgrammeWorld Health Organization Vaccination of high-risk groups Contraindications to vaccination Adverse events associated with particular vaccines Pathogenesis of serious adverse reactions

3. Global Training Network ProgrammeWorld Health Organization 5 doses YY Tetanus toxoid N (need studies)Y Yellow fever As for uninfected YY HepB 6 and 9 monthsY (depends)Y Measles 0, 6, 10, 14 weeks Y (IPV if available) Y OPV 6, 10, 14 weeks YY DTP BirthN Y BCG Optimal timingSymptomaticAsymptomaticVaccine WHO/ UNICEF recommendations for vaccination of HIV-infected children and women of childbearing age

4. Global Training Network ProgrammeWorld Health Organization True contraindications are rare Current serious febrile illness delay vaccine administration History of severe AEFI after previous dose Evolving neurological disease avoid whole cell pertussis vaccine (e.g. uncontrolled epilepsy) Type 1 hypersensitivity to egg - avoid yellow fever & influenza but can use vaccines made in chick fibroblasts Symptomatic HIV avoid BCG and yellow fever WHO Immunization Policy 1996

5. Global Training Network ProgrammeWorld Health Organization Anaphylactic reaction to neomicin, streptomycin or polymyxin B IPV Immunodeficiency, or immunodeficient household contact* OPV Encephalopathy within 7 days of administrationDTP Anaphylactic reaction to vaccine or vaccine constituent Severe febrile illness All vaccines ContraindicationVaccine * Risk benefit assessment when administered to HIV positive individuals Adopted from Plotkin pg 66-67

6. Global Training Network ProgrammeWorld Health Organization Anaphylactic reaction to common baker’s yeastHepatitis B Anaphylactic reaction to egg, immunodeficiencyYellow fever NoneHib Anaphylaxis, pregnancy, immunodeficiency* MMR ContraindicationVaccine * Risk benefit assessment when administered to HIV-positive individuals Adopted from Plotkin pg 66-67

7. Global Training Network ProgrammeWorld Health Organization Type 1 hypersensitivity reaction Circulatory failure Bronchospasm +/- laryngospasm/laryngeal oedema respiratory distress May include pruritis, flushing, angioedema, seizures, vomiting, abdominal cramps & incontinence Occurs in previously sensitized individuals

8. Global Training Network ProgrammeWorld Health Organization Reported less from developing countries Less sensitization? Less reporting? Anaphylaxis is rare (1/1 000 000 vaccinations) Fainting is common Untrained staff may misdiagnose fainting/dizziness for anaphylaxis or vice versa Administration of adrenaline in a faint may be dangerous PROMPT MANAGEMENT IS VITAL!

9. Global Training Network ProgrammeWorld Health Organization WHO case definitions are used here Lack of standardized case definitions in the literature e.g. fever The Brighton collaboration developing case definitions for AEFI promoting global implementation of these definitions secretariat@brightoncollaboration.org http://brightoncollaboration.org

10. Global Training Network ProgrammeWorld Health Organization Particularly associated with measles and DTP vaccination (pertussis component) febrile seizures Temp >38 afebrile seizures Temp normal Febrile seizures more common with pertussis An association with non-febrile seizures has not been proven

11. Global Training Network ProgrammeWorld Health Organization Disseminated BCG widespread infection, 1-12 months after BCG usually in immunocompromised individual confirm by isolation of Mycobacterium bovis BCG strain treat with antituberculous regimen including Rifampicin and Isoniazid Osteitis/osteomyelitis infection of the bone with M bovis BCG strain management as above

12. Global Training Network ProgrammeWorld Health Organization Suppurative lymphadenitis occurs within 2-6 months of BCG vaccination case definition 1 lymph node> 1.5 cm in size/draining sinus over a lymph node usually occurs in the axilla, on the same side as innoculation Management heals spontaneously over months only treat if sticking to skin or draining surgical drainage and local installation of antituberculous drug systemic Rx is ineffective

13. Global Training Network ProgrammeWorld Health Organization

14. Global Training Network ProgrammeWorld Health Organization

15. Global Training Network ProgrammeWorld Health Organization Possibly associated with measles & pertussis vaccine Case definition of encephalopathy 2 out of 3 of seizures alteration of consciousness lasting for one day or more distinct change in behavior for one day or more Temporal relationship within 48 hrs with DTP within 7-12 days after measles or MMR

16. Global Training Network ProgrammeWorld Health Organization An analysis of claims for encephalitis following measles vaccine in the USA found clustering of events 8-9 days after vaccination (Wetbel 1998, Duclos 1998) This supports, but does not prove, the possibility that measles vaccine was causative Risk is less than 1 case per million

17. Global Training Network ProgrammeWorld Health Organization >2 killed antigens killed and live antigens >2 live antigens None can be given simultaneously/at any interval None (except cholera and yellow fever) 4 weeks, if not administered simultaneously (except OPV can be given any time before, after/with MMR and oral typhoid

18. Global Training Network ProgrammeWorld Health Organization Restore respiratory and cardiovascular function SQ adrenaline: counteract bronchoconstriction and vasodilation Crystalloids - restore intravascular volume & prevent shock Establish and maintain airway Corticosteroids to prevent “late-phase” reaction Aminophylline as adjunctive for bronchospasm Antihistamines not effective as primary therapy

19. Global Training Network ProgrammeWorld Health Organization A one-year-old child died within 12 hours of receiving measles vaccine. It was reported as a possible anaphylaxis because of its rapid onset. Investigation found that the vaccine used was likely to have been reconstituted some days prior to this particular use. Cause: Non sterile injection: NOT ANAPHYLAXIS!!!

20. Global Training Network ProgrammeWorld Health Organization Case An outbreak of lymphadenitis three months after BCG immunization was traced to a switch to a different strain of vaccine. The investigation also highlighted a number of programme errors (vaccines not properly reconstituted, and injections not given intradermally). Cause: Vaccine reaction compounded by programme errors

21. Global Training Network ProgrammeWorld Health Organization Vaccine BCG OPV Measles DTP Estimated rate of serious reactions 1/1000 to 1/50 000 doses 1/3 million doses for 1st dose OPV 1/1million doses 1/750 000 WHO web site - Dealing with adverse events - 2/19/99